European Stars And Stripes (Newspaper) - November 22, 1988, Darmstadt, Hesse                                 provoking physician May be a health Hazard by Daniel Goleman new York times a novel study has provided the first glimpses what Braila experienced Doc Lor find most provoking in their  patients who Are most troubling to seasoned physicians the stud found Are those who pose a threat to the physician s sense of professional integrity patients who Are disrespectful critical or demeaning or instance Are far More irritating than those who disregard the doctor s instructions or who cannot pay their Bills the study Lound. Experts who have studied the ways doctors make decisions on diagnosis and treatment say the findings have disturbing implications patients who provoke an emotional reaction in their physicians May unwittingly interfere with the physician s diagnostic accuracy and treatment decisions. For example resentment toward a Patlen. These experts say might Lead doctors to to loss vigilant and thorough in their treatment. Medical educators Hope research on the problem will help them warn medical students about the danger or even change the attitudes that underlie the reactions. If a doctor s sell esteem relies too much on his professional self image hell be vulnerable to patients who seem ejecting in some Way said John Maltzberger a psychiatrist at Harvard medical school adding it a Polcyn Tiff problem  the new study is described in the current Issue of  in an article by Robert c. Smith a psychiatrist and George Zymny a psychologist both at Michigan state University medical school they sent a questionnaire to half the internists in St Louis a total of 330 59 replied. The questionnaire described 33 actions by patients that earlier interviews with physicians suggested might be irksome. The internists indicated How irritating they found each situation the situations rated most troubling wore those in which a patient somehow challenged the physician s professional integrity or self esteem. These included a patient s expressing outright criticism disrespect or anger toward the physician ignoring what the physician is trying to say and insisting on procedures the physician Levels Are unnecessary Somo of the situations the physicians found most irritating were related to the patients medical condition rather than their actions. The physicians indicated that they Ware highly upset when a patient s condition was baffling or when a Palien Gol worse despite the physician s Best efforts. Less upsetting but still troubling Wero patients whose problems demanded unusual amounts of Lime who were seductive or whose personal Hygiene was inadequate by and Large though the physicians Wero less upset by patients who were themselves demanding or upset but who did not directly threaten Tho physicians self Sleem. On the other hand the physicians were Only mildly bothered by patients whose problems had Little to do with he physician like those who rambled or who exposed them to a communicable disease such As tuberculosis while earlier studios of reactions to patients had bean done mainly with medical students or residents the St. Louis Survey was tha first to study seasoned physicians. The average age of those surveyed was so the average number of years since graduating medical school was 25. The researchers expected to find that the More experienced the clinicians were the less disturbed they would is by their patients. Instead the results. Showed that experience made no a Florencei highly seasoned physicians were As bothered by threats to their professional integrity As were fledgling physicians Bui the younger doctors generally were disturbed by a wider Range of patients characteristics. These included Lor instance patients who gave unreliable accounts of their medical history those who spoke Only a foreign language and so needed a translator present and those who raised troubling personal problems that were irrelevant to their medical condition. Medical schools anticipating the emotional reactions physicians May have to difficult patients have begun to teach students How to handle such situations More skilfully. We try to show our students How to Deal concretely with these difficult situations said Mack Lupkin or. Director of primary care at  University medical school Lipkin is also a member of the task Force on training medical interns of the society of general internal Medicine to one training laps used with interns troubling situations Are depicted. They include a haughty patient who demands to see a More senior physician one who accuses a phys Clen of incompetence and improper care for not ordering a complicated test and one who is angry at the physician Lor not curing Bach pain. We teach solutions to these problems said Lipkin. First the physician should realize that these patients have some Good reason to Lee the Way they do and thai the reason usually Doorn l have anything to do with you. So the next step is to validate their feelings. That Way you become their ally not an  often for instance it s the patients ear about their condition Lupkin said. It you got to that the rest melts away.". -. -,.-. The ways patients can distress their doctors in a study of 59 experienced internists the following kinds of patient behaviour out of a list of 33 statements were rated As particularly Likely to stir Strong emotions in the doctors the patient is disrespectful critical or demeaning of me. The patient wants me to certify him her disabled but i Don l think he she is. The patient wants lab tests or medications such As narcotics but i think they Are unnecessary. The patient is getting worse even though i know i be done everything possible the patient presents what appears to be a serious problem thai i do not understand. The patient is seductive making suggestive remarks or behaving in a sexual Way toward me the Patien expresses anger toward me the patient keeps trying to control our interaction by interrupting not listening or. Changing the subject. The patient wants me to fill out Many Legal  papers the patient has poor general Hygiene is malodorous or has an unkempt appearance. 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